WHAT HAPPENED? 7/17/2017. Children are not small adults #FSHP2017

Transcription

1 FSHP Disclosure Small People in Big Trouble: Pharmacotherapy of Common Pediatric Emergencies Katie Wassil, PharmD, BCPS I do not have (nor does any immediate family member have) a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation. Objectives Technician Objectives Review the differences in drug disposition between the adult and pediatric patient Describe the most common critical conditions leading to hospital admission and their treatment in the pediatric patient Discuss differences from adults and therapeutic options for pediatric patients in cardiac or respiratory emergency Discuss tools available to decrease risk of medication errors during pediatric emergencies Evaluate the most useful drug information resources for pediatric drug information Recognize differences in drug formulations between the adult and pediatric patient Discuss the differences between adult and pediatric treatment options for the most common pediatric emergencies Discuss tools available to decrease risk of medication errors during pediatric emergencies Identify the most useful drug information resources for pediatric drug information WHAT HAPPENED? Children are not small adults 1

2 With permission; Kearns et al NEJM ;12 With permission; Kearns et al NEJM ;12 Out with the Old Asthma Young s rule: (Age in years * Adult dose) (Childs age in years + 12 years) Clark s rule: (Wt in pounds * Adult dose) 150 pounds 7.1 million (9.6%) children in United States Exacerbations account for 640,000 emergency room visits annually Most common diagnosis of hospitalization $56 billion per year in cost of disease ED visit- 8% Hospitalizations- 50% Pardue et al. J of Asthma 2016; 53(6) Mortality by Age Group Asthma Mortality 2015 Death Rate per 1,000,000 CDC Advance Data; 381: Dec

3 Who is at risk? Management Previous severe exacerbation (intubation or ICU admission) In the past year > 2 hospitalizations for asthma >3 ER visits Using more than 2 SABA canisters/month Poor perceiver Low socioeconomic status CV, chronic lung or psychiatric disease NAEPP guidelines Last udpated 2007 GINA guidelines Evaluated biannually Updated annually Asthma Exacerbation Severity Breathlessness Mild Moderate Severe Resp Arrest Imminent While walking Can lie down While at rest Prefers sitting While at rest Sits upright Talks in Sentences Phrases Words Alertness May be agitated Usually agitated Agitated Drowsy or Confused Respiratory Rate Increased Increased > 30/min Accessory Muscles Wheeze Adapted from NAEPP guidelines Usually not Commonly Usually Paradoxical thoracoabdominal movement Moderate, often only end expiratory Loud: throughout exhalation Usually loud: throughout inhalation and exhalation Absence of wheeze Pulse < >120 Bradycardia FSHP Status Asthmaticus Pathophysiology NAEPP Asthma Guidelines

4 Management Beta Agonists 3 principle goals Correct hypoxemia Supplemental O2- usually in mod-severe Reverse airflow obstruction SABA (short acting B 2 agonist) Early systemic steroids- if not responding to SABA Reduce likelihood of relapse Short course of oral steroid Beta agonists- mediate bronchodilation by stimulating B 2 receptor on bronchial smooth muscle Agents Albuterol- nebulized Terbutaline- IV Levalbuterol-nebulized Epinephrine- SubQ Long acting B 2 agonists are contraindicated in status asthmaticus Beta Agonists Albuterol Adverse Effects Tachycardia QT prolongation Dysryhthmias Hyper/Hypotension Tremor Hypokalemia Continuous neb vs MDI MDI 4-8 puffs q20 min for 3 doses then q1-4h PRN Affords parent/patient teaching on proper technique and use Nebulized 0.15 mg/kg (min 2.5 mg) q 20 min then mg/kg (max dose 10 mg) q1-4h PRN 0.5 mg/kg/hr (10-40 mg/hr) Ipratropium Steroids Diminishes cholinergic bronchomotor tone, decreases mucosal edema and secretions Given in conjunction with albuterol, not single agent mg neb up to 3 doses Improves lung function and decreases hospitalizations in moderate to severe exacerbations Only effective in ED setting Decrease inflammation and mucous production Enhance efficacy of bronchodilators Moderate-Severe exacerbations Prednisone 1-2 mg/kg/day for 3-10 days (max 60 mg/day) Dexamethasone mg/kg/day 1-2 doses (max 16 mg/day) Short bursts of steroids have shown no effect on bone density, height or adrenal function 4

5 Prednisolone vs. Dexamethasone Meta analysis of 6 RCT comparing the two Determine if single dose IM/PO dexamethasone was equivalent to 5 day course of prednisolone Primary outcome was unscheduled return visits Clinic, ER, hospital admission Secondary outcome- vomiting in the ER or home Incidence of Relapse Group 1 Keeney et al. Pediatrics 2014;133(3): Keeney et al. Pediatrics 2014;133(3): Incidence of Vomiting in ER Incidence of Vomiting at Home Group 1 Group 1 Keeney et al. Pediatrics 2014;133(3): Keeney et al. Pediatrics 2014;133(3): Conclusions IV Magnesium No difference in primary outcome Fewer patients experienced vomiting Oral dexamethasone dosing possible benefits: Increase parent/patient satisfaction Increase compliance Group 1 In severe exacerbations that have failed conventional therapies (still severe after 1 hour of treatment): Improvement in pulmonary function Decrease in hospitalization MOA: Smooth muscle relaxant Blocks Calcium entry into cell and release from endoplasmic reticulum Dose: mg/kg (up to 2 grams) IV over 20 minutes 5

6 Baby Brown Differential BB is a 6 day old, 38 week GA that went home after uneventful delivery. 4 days later parents called EMS b/c the baby was found blue with minimal respirations and weak pulses in his crib 5 minutes after they put him to bed. Hypovolemic or Septic Shock ABCs Fluids Pressors ATB Covering neonatal meningitis bugs and HSV Shock Type Preload Contractility Afterload SHOCK Hypovolemic Decreased Normal or Increased Septic Decreased Normal to Decreased Increased Variable Cardiogenic Variable Decreased Increased AHA; PALS Provider Manual 2015 Septic Shock 20,000 inpatient admissions and 800 deaths per year Early Goal Directed Therapies improves survival in adults Pediatric guidelines Surviving Sepsis Campaign guidelines updated Adult and pediatric Pediatric SSC Guidelines- Early Goal Directed Therapies Within first hour Fluids Antibiotics Vasoactives Goals Capillary refill of less than 2 seconds Normal BP for age Normal pulses Warm extremities Normal mental status UOP > 1 ml/kg/hr Workman et al. Pediatr Crit Care Med 2016;17:e Dellinger et al Crit Care Med 2013; 41(2) 6

7 Let s Save Lives Anyone Can Do it! Successful shock reversal by community physicians prior to transport 96% survival >9 fold increase in odds of survival Each hour of persistent shock associated with >2 fold increase in odds of mortality Fluids Normal Saline, Lactated Ringers ml/kg 5-10 ml/kg If heart or lung issues suspected Administer over 5-20 min Administer as needed to support BP and perfusion Pediatrics 2003; 112: Hypotension in pediatrics Systolic neonates < 60 mmhg 1 mo-12 mo <70 mmhg 1 yo-10 yo <70 mmhg + (2 X age in years) >10 yo <90 mmhg Vasoactives Norepinephrine 1 st line for fluid refractory warm shock mcg/kg/min Epinephrine Cold shock Inotropic- beta effects SVR- alpha effects 0.1 mcg/kg/min AHA; PALS Provider Manual 2015 Baby Brown Differential BB is a 6 day old, 38 week GA that went home after uneventful delivery. 4 days later parents called EMS b/c the baby was found blue with minimal respirations and weak pulses in his crib 5 minutes after they put him to bed. Non-accidental Trauma Support ABCs Fluids Protect brain Normalize sodium 3%NaCl, mannitol, pentobarbital If evidence of increased ICP Monitor for seizures 7

8 Neuroprotective Strategies Baby Brown Normalize Sodium NS in IVF 3%NaCl meq/ml Dose: 2-4 ml/kg over 30 minutes Dose: ml/kg/hr- titrate to ICP Central line or IO BB is a 6 day old, 38 week GA that went home after uneventful delivery. 4 days later parents called EMS b/c the baby was found blue with minimal respirations and weak pulses in his crib 5 minutes after they put him to bed. Post resuscitation and intubation child now having facial twitching and arm movement. Status epilepticus Benzodiazepines Seizure lasting > 5 minutes Fosphenytoin/Phenytoin Meds STAT Phenobarbital Sem Ped Neuro 2010; 17: Valproic acid Benzodiazepines Fosphenytoin/Phenytoin Lorazepam (IV) 0.1 mg/kg up to 4 mg Diazepam (IV) 0.2 mg/kg up to 5 mg 0.5 mg/kg IV form given rectally Midazolam Buccal, Intranasal- 0.2 mg/kg Load with mg PE /kg Fosphenytoin max- 3 mg PE/kg/min (150 mg PE/min) Phenytoin 1 mg/kg/min (50 mg/min) Does not treat seizures due to toxin ingestions Lexi Comp Pediatric Dosing Handbook 23rd edition Lexi Comp Pediatric Dosing Handbook 23rd edition 8

9 Fosphenytoin/Phenytoin Levetiracetam (Keppra) Fosphenytoin IV or IM Dilute with NS or D5W to < 25 mg/ml Phenytoin IV only Dilute with NS to < 10 mg/ml Loading Dose- 30 mg/kg Administration rate- 5 mg/kg/min Preparation: Comes as 500 mg vial (100 mg/ml) Dilute 1:1 with NS Lexi Comp Pediatric Dosing Handbook 23rd edition Sem Ped Neuro 2010; 17: Phenobarbital 20mg/kg load Max rate 1 mg/kg/min Adverse Effects Sedation Respiratory depression Hypotension Review of 5 AEDs in Benzodiazepine Resistant Status Epilepticus Phenytoin Phenobarbital Valproic Acid Levetiracetam Lacosamide Primary outcome: cessation of seizure Lexi Comp Pediatric Dosing Handbook 23rd edition Efficacy Summary Baby Brown BB is a 6 day old, 38 week GA that went home after uneventful delivery. 4 days later parents called EMS b/c the baby was found blue with minimal respirations and weak pulses in his crib 5 minutes after they put him to bed. Seizure 2014; 23:

10 Differential Alprostadil (Prostin) Undiagnosed CHD Fluids Start lower if suspecting heart failure Support CO and BP Epinephrine Dopamine Alprostadil STAT Preparation: 500 mcg/ml diluted in 49 ml NS or D5W Usual Dose: mcg/kg/min Prostaglandin E1- relaxes smooth muscle of ductus arteriosus TZ TZ is a 3 yo previously healthy WM found down at home. CPR initiated by mom and rescue is en route with patient. What medications should you prepare? Questions to think about What weight or Broselow color is the patient? Are we all talking in the same units? Double check all calculations Access Intraosseous (IO) Fluids Blood products Catecholamines Endotracheal- last line LANE Lidocaine, Atropine, Naloxone, Epinephrine AHA; PALS Provider Manual

11 Epinephrine Epi- 1:10,000 prefilled syringe (0.1 mg/ml) Dose- 0.1 ml/kg (0.01 mg/kg) IV push What is different? Cardiac arrest is usually due to respiratory failure or shock in pediatrics Exceptions Congenital heart disease Witnessed arrest or collapse cab versus Cab Dilated cardiomyopathy Long QT syndrome Ingestion Sharp blow to the chest Myocarditis Causes of Pediatric Cardiac Arrest Out of Hospital In Hospital Respiratory Failure Upper Airway Obstruction Lower Airway Obstruction Disordered Control of Breathing Lung Tissue Disease Hypotension Hypovolemic Shock Cardiogenic Shock Distributive Shock Cardiac Arrest Respiratory Failure Upper Airway Obstruction Lower Airway Obstruction Disordered Control of Breathing Lung Tissue Disease Hypotension Metabolic/Electrolyte Hypovolemic Shock Distributive Shock Cardiogenic Shock Toxicologic 2015 AHA Guidelines Arrhythmia Arrhythmia adapted from PALS Guidelines To Err is Human Caring for children in the emergency setting is especially prone to error due to environmental and human factors. High stress High activity Constant urgency Missing information Capturing errors during a true emergency is difficult Strategies to decrease errors difficult to define Pediatrics 2007; 120(6): Larose et al. Pediatrics 2017;139(3) 11

12 What makes the ER unique? Hectic, chaotic, interruptions Communication Handoffs, lots of cooks in the kitchen Verbal orders Minor issues Life and death situations Language barriers What makes pediatric patients unique Manual dosing Lots of nurse mixing of partial vials Few standard dosing Weight based dosing Weight errors Inability of the child to communicate problems What s the weight? Dosing in mg/kg Kilograms vs pounds 1 kg = 2.2 lb Computer errors What s the dose? mg/kg dosing Keep adult maxes in mind Excel spreadsheets Broselow tape Broselow carts Common sense E Broselow 12

13 Phone a Friend High-Reliability Organization High risk environment that maintains low risk of harm Mishap is possible at any time with the right circumstances Keep in mind no person or organization is perfect Conclusions Don t let pediatric patients intimidate you References Calculators Experienced nurses Pharmacists 13